It has happened, of course—and not infrequently. Just in this century, American presidents who continued to serve in ofﬁce while seriously neurologically impaired include Woodrow Wilson, Franklin D. Roosevelt, and Dwight D. Eisenhower. In the ﬁrst two, there is a credible historical case that the results were catastrophic on a world scale. But the real question is: Could it happen again?
Neurologist James Toole headed a Working Group on Presidential Disability, established in 1994 at the invitation of former President Jimmy Carter and Atlanta’s Carter Center, that made strong recommendations for guarding against a recurrence, but little has been done. As a result, says Dr. Toole, a time bomb (or a somewhat larger explosive) is ticking away. There are steps that would be simple — though not politically easy—to implement.

Human society and its governance are the ultimate expression of cerebral activity. In times past, when impulses such as “kill or be killed,” arising from the hypothalamus or limbic system, overrode the forebrain’s control, relatively limited consequences followed. A stone thrown by a designated hitter killed Goliath in single combat; now our killing tools are so efﬁcient that a few deranged individuals using nuclear and biological weapons can devastate continents.

Because the consequences of uncontrolled actions by leaders can be so far-reaching, those knowledgeable about brain function should makes themselves heard now—before we have a global disaster—to promote change in social systems that tolerate impaired individuals in power. I believe that leaders—local, national, and international—should undergo periodic assessments of their cognitive and behavioral functioning, as well as physical examinations, to ascertain if they have the intellectual and emotional capacity to make responsible decisions.

In certain countries, where leadership is based solely on power, there are shameful instances of senile ofﬁcials holding ofﬁce even when comatose—as happened with Marshal Tito in the former Yugoslavia and General Bourgiba in Tunisia. There is no doubt that the 1922 stroke that rendered Vladimir Ilyich Lenin partially paralyzed compromised his ability to speak and enabled the Communist party secretary, Joseph Stalin, to usurp control against the will of the Commisariat and, speciﬁcally, of Lenin. This made possible the liquidation of millions of kulaks by a paranoid leader. Arguably, senility in Mao Tse-tung of the People’s Republic of China resulted in the deaths of even more millions.

In the United States, election or selection for most ofﬁces requires only citizenship, absence of a criminal record, and attainment of a minimum age. Candidates for ofﬁce have concealed life-threatening diseases, causing wrenching conﬂicts in their physicians between the obligation to keep conﬁdential what is revealed by their patient and the responsibility to inform the public about life-limiting or judgment-impairing disease.

Once ofﬁcials are elected or appointed, there is no legal requirement for periodic physical, mental, or behavioral examinations while they are serving in ofﬁce. When the average life span was 60 years, senility was a less common problem. Now, with the graying of America (and soon the world), devastating neurological diseases and other conditions have a much greater likelihood of wreaking havoc on an individual’s mental functioning. Isn’t it time for the law to require health examinations, and public revelation of the results, before election and periodically thereafter while an individual is serving in ofﬁce—just as there are legal protections of the public in other areas of society? After all, we have laws governing the packaging of foods, construction of automobiles, and periodic inspection for continuing registration and licensing of vehicles and drivers. Why don’t we have similar requirements for public ofﬁcials (as we have already for aviators)? Unfortunately action is stalled, in part because it contravenes traditions of conﬁdentiality in matters relating to health. Society desperately needs correction of this Achilles’ heel before it is too late.

THE COGNITIVELY DISABLED U.S. PRESIDENT

I became interested in this problem in the 1960s, when it came to light that President Franklin D. Roosevelt, in addition to being physically exhausted, might also have had vascular dementia caused by uncontrolled hypertension and congestive heart failure when he and British Prime Minister Winston Churchill negotiated with Joseph Stalin at Yalta near the end of World War II. Subsequent revelations by Churchill’s physician, Lord Moran, suggest that Churchill also suffered from increasing dementia during this critical period. Few now dispute that Roosevelt and Churchill were out-negotiated by Stalin, with resulting arbitrary divisions of Poland, Germany, Vietnam, and Korea that sowed the seeds of subsequent hot and cold wars.

Barely ﬁve years after Yalta, I was mobilized to serve as battalion surgeon in Korea during the so-called “police action” by the United Nations. There, I witnessed the deaths of hundreds, the wounding of thousands, the winter migration of many thousands more who died en-route south, and the wholesale destruction of several cities. Since then, I have speculated that it may all have begun in 1945, with the cognitive impairment of two aging men who made faulty decisions on behalf of the world’s most powerful countries.

It requires considerable (though not implausible) extrapolation to go from decisions by impaired leaders at Yalta to war in Korea. A far more direct linkage has been established in the case of President Woodrow Wilson. After the armistice ending World War I, Wilson joined the allied leaders at Versailles in devising a peace treaty, which included provision for a League of Nations as a global forum for averting future wars. Signed by the Allies, the treaty was presented to the U.S. Senate for ratiﬁcation. Senator Henry Cabot Lodge of Massachusetts led strong opposition to ratiﬁcation on the grounds that the League, as planned, was unworkable, and would bring the United States under control of an international body.

In October 1919, Wilson embarked on a cross-country campaign to enlist popular opinion on behalf of the treaty and the League. Previously—in April 1919— Wilson had suffered an unpublicized stroke in Paris; now, as he undertook the three-week, 8,000-mile speaking tour, he had a major stroke. On October 10, there was a third and incapacitating attack. Vice President Thomas Marshall, although asked to serve as acting president, demurred because of Mrs. Wilson’s resistance and the opinion of Admiral Gary Grayson, Wilson’s physician, that the president could continue to carry out the duties of ofﬁce.3

As rumors of the president’s disability spread, Congress sent Senator Albert Fall to interview Wilson and report on his condition. Historian Paul Johnson sets the scene:4

He found Wilson with a long, whitebeard but otherwise apparently alert (hecould concentrate for ﬁve to ten minutesat a time). When Fall said, “We, Mr. President, have all been praying for you,” Wilson foxily replied, “Which way, Senator?”—a remark interpreted as evidence of his continuing sharpness. Fall was with Wilson only a short time, and being an egoist did most of the talking. So Wilson passed muster and the farce continued.

In fact, Fall did not examine Wilson or even have a lengthy discussion with him because Grayson and Edith Wilson were hostile and colluding in hiding the degree to which the president was disabled. Here we see the crux: Who was in a position to pass judgment? Who had the access, the clear authority, and the responsibility to the nation to make Wilson’s incapacity public?

Here we see the crux: Who was in a position to pass judgment? Who had the access, the clear authority, and the responsibility to the nation to make Wilson’s incapacity public?

Thereafter, Mrs. Wilson handled all state matters. She later recalled that she began her stewardship by studying all papers and reports that came to the president’s desk and trying to digest them. She then decided what needed to be seen by the president. In effect, she became the acting president of the United States at a time of decision for America and Europe, and momentous stakes for the world. In the guise of helping the disabled president to recover, she facilitated or obstructed decision making.

This unsatisfactory state of affairs continued throughout the remaining 18 months of the Wilson presidency and was kept secret by the Cabinet and the top ofﬁcers of the government. Many believe that Wilson’s strokes resulted in rejection of the Treaty of Versailles by the Senate, crippling the new League of Nations and leading to the subsequent power vacuum in Europe— a void eventually ﬁlled by a resurgent Germany led by the Nazi party.

In theory, this situation could not occur again; yet there are suspicions that there may have been unofﬁcial decision making by those near to more recent presidents, when they were unable to make the decisions themselves. This was certainly true of President Dwight D. Eisenhower, whose capacity to speak was affected by a stroke. It may have been the case following the wounding of President Ronald Reagan.

THE TWENTY-FIFTH AMENDMENT

Why does our nation tolerate this appallingly dangerous ﬂaw in our system? Can there be any brake on this unregulated system— or must we live in danger of catastrophe? A ﬁrst step was taken in 1965, when Senator Birch Bayh proposed an amendment to the U.S. Constitution. On February 10, 1967, Article 25 was ratiﬁed by a sufﬁcient number of state legislatures. In it, succession is clearly deﬁned in cases of removal of the president from ofﬁce by death or resignation. The vice president shall become president, as happened when President Richard M. Nixon was replaced by Vice President Gerald R. Ford.

Section 2 is equally clear on succession to the ofﬁce of the vice president, as occurred when Ford was appointed vice president after the resignation of Spiro T. Agnew.

Section 3 is straightforward. If the president voluntarily submits a written statement that he is unable to discharge the powers and duties of his ofﬁce, they shall be discharged by the vice president as acting president until the president submits another document stating that he has recovered. This sequence occurred when President Reagan transferred power to Vice President George Bush in anticipation of undergoing general anesthesia for colon surgery and then resumed ofﬁce immediately thereafter.

In Section 4, however, there seems the potential for a serious dilemma:

Whenever the vice-president and a majority of either the principal ofﬁcers of the executive department or of such other body as Congress may by law provide, transmit to the president pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the president is unable to discharge the powers and duties of his ofﬁce, the vice president shall immediately assume the powers and duties of the ofﬁce as acting president.

What is the mechanism for determining that the president is unable to serve? How does one inform the president that he is not capable of performing in ofﬁce? Judging from past experience, it would require the most extreme conditions for the vice president or members of the cabinet to remove their leader. They have a built-in political incentive to maintain the status quo because, if the president is removed, the cabinet that serves him may be replaced as well. Furthermore, these ofﬁcials are not medical professionals and so cannot have full insight into the dangers of having a mentally impaired leader.

There is an even greater problem in implementation of the next part of Section 4. It states:

Thereafter, when the president transmits to the president pro tempore of the Senate and the Speaker of the House of Representatives his written declaration that no disability exists, he shall resume the powers and duties of his ofﬁce unless the vice-president and a majority of either the principal ofﬁcers of the executive department or of any such body as Congress may by law provide, transmit within four days to the president pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the president is unable to discharge the powers and duties of his ofﬁce. Thereupon Congress shall decide the issue, assembling within 48 hours for that purpose if not in session.

These two clauses conceal potential stumbling blocks. Together, they could enable a cognitively impaired President who lacked insight into his mental deﬁciency to obstruct governmental procedures for removal from ofﬁce (or to resume ofﬁce), despite persistent deﬁcits. Only a specially trained physician has the skills to determine the presence, treatment, and prognosis for neurologic and psychiatric disease.

THE PHYSICIAN’S ROLE

The president’s physician is responsible for medical and neurological decisions about the president’s physical and mental health. Unfortunately, there is no statutory requirement that the president submit to periodic health examinations or that the results of these examinations be made known. Unfavorable reports can be suppressed or ignored with legal impunity.

In many cases, there are two presidential physicians whose roles, responsibilities, and reporting loyalties differ. One is a military physician appointed to serve all members of the executive branch, including the president. This ofﬁcer is responsible for the health of the president at home or abroad and, consequently, for emergency care, and reports to the Surgeon General of the United States through the commanding ofﬁcer of the branch of the military in which the physician serves.

The president also can appoint a personal physician and has traditionally chosen a close friend. Consequently, there is a special bond between the two, and the customary conﬁdentiality between physician and patient is maintained. Because of the traditional doctor/patient relationship, the personal physician has no ofﬁcial obligation to reveal any of the ﬁndings. Divergent views and conﬂicting recommendations for management of presidential health abnormalities have arisen because of these different responsibilities.

Presidential disabilities known to physicians have been manipulated by the cabinet members, using “positive spin” in order “not to alarm the public.” For example, when President Eisenhower had his stroke, the public, for political reasons, was not immediately informed. Vice President Nixon issued the following statement:

The neurological consultants unanimously agreed that the President’s recovery to date is such that it permits him to attend the Paris Meeting. The decision of the neurological consultants was concurred in by General Howard Snyder, personal physician to the President; Major General Leonard D. Heaton, Commanding General; and Brigadier General Thomas W. Mattingly, Chief of the Cardiological Service, Walter Reed General Hospital.

Dr. Frank Forster, who with Dr. H. Houston Merritt were the consulting neurologists, informed me that: “The press release was written not only by the physicians involved, but Vice President Nixon, the Attorney General, and the White House staff were all involved.”6

In 1994, Dr. Mattingly recounted to me: “I had not concurred in the decision pertaining to the president’s planned participation in the NATO conference because I feared a repeat embolization. Snyder’s failure to have me take part in the examination on this date, I thought, was purposeful. He was afraid that the president would ask my opinion directly as he had done on previous occasions, and Snyder knew that I would give my honest judgement.”7

Ironically, President Nixon wrote, some years later:

As we sat in [Mao Tse-Tung’s] book-cluttered ofﬁce in the Forbidden City, I was reminded of President Dwight Eisenhower’s intense frustration after suffering a stroke in 1957. A few days after he returned to the White House from the hospital, he described to me the ordeal that simple speech had become. He complained that when he wanted to say “ceiling,” it would come out “ﬂoor.” When he wanted to say “window,” he would say “door.”8

Situations like these must be prevented by better deﬁning medical duties and authority, with one individual unambiguously in command. The Working Group on Presidential Disability, described below, considered this problem in depth, concluding that a senior physician must be in command to make responsibilities clear and resolve the problem of the responsibility of the physician to reveal information normally held conﬁdential but of supreme importance to the public.

THE WORKING GROUP ON PRESIDENTIAL DISABILITY

At the invitation of President Carter, a Working Group on Presidential Disability was established in May 1994 to address these problems.9 It was co-chaired by the late Arthur Link (a leading historian and biographer of Woodrow Wilson) and me. Members of the Group were from neurology, general medicine, neuropsychology, psychiatry, history, political science, law, and journalism. We deliberated at length on all aspects of the topic of presidential disability; our recommendations were published by Bowman Gray Scientiﬁc Press10 and a synopsis published in the Archives of Neurology.11

The Working Group afﬁrmed that many presidents have experienced health crises that drastically impaired their ability to concentrate on important intellectual and political problems. We resolved that there should be a contingency plan, agreed between the president-elect and the vice-president-elect, stipulating how they would manage a disabling medical or cognitive impairment. We further resolved that this plan should be completed and made public before inauguration.

A means for appropriate dissemination of information on the health of the president must be devised by the individuals directly involved, particularly the cabinet, the vice president, the spouse of the president, and the president. Periodic ﬁtness examinations, similar to those required of individuals in many walks of life—notably aviation—should be a requirement for continuing to serve in ofﬁce. Finally, there must be a medical physician at cabinet level to serve the president as his personal physician and interact with the ofﬁcers designated by the Twenty-ﬁfth Amendment as responsible for determining the ability of the chief executive to fulﬁll the duties of ofﬁce.

The Working Group also considered, but did not resolve, the dual role of the presidential physician, which requires both conﬁdentiality and the duty to report ﬁndings to the public or to a supervising body. All agreed that this physician was critical to the early identiﬁcation of presidential inability, so that preventive or remedial action could be taken with equal attention to the health needs of the president and the requirements of a mentally competent individual to be commander-in-chief of the United States. These conﬂicting responsibilities must be resolved.

A minority of the Working Group believed that a panel of physicians should be appointed by Congress or another body to assess annual medical reports on the president by his physicians and the ﬁtness of the president for continuing service. This “Supreme Court” approach would remove from the physicians caring for the president the responsibility for revealing or maintaining conﬁdence and secrecy. Those favoring this view believe it would remove decision making from the political arena and ensure that an objective, unbiased assessment would be revealed to the public.

Those who believe that this is not the best method suggest that appointment to the panel inevitably would become politicized and that such decision making does not justiﬁably belong to physicians in any case. They contend that determining the president’s ability to govern is not a medical but a political decision that must be solved by the vice president and Cabinet, based on information provided by the physicians. They argue that the U.S. Constitution requires that this judgment be made by those elected or appointed to ofﬁce, not by physicians, who traditionally have been in an advisory capacity. Herein lies the greatest problem of all: Those who serve the president naturally wish to preserve that president in ofﬁce and will tend either to ignore or suppress vital information politically unfavorable to the status quo.

Personally, I favor use of a single senior physician, whose duty it would be to serve both the nation and the president. The role of military physicians has always been clear: They serve ﬁrst the good of the nation and second the individual, as demonstrated in their decision making regarding ﬁtness for duty in many military roles, including that of the commander-inchief of the United States. The “health ﬁtness report” is objective, standardized, and generally accepted. It could be modiﬁed to suit the special circumstances of the presidency. What should be done with these ﬁndings, however, represents a most complicated problem, because of the variety of diseases to which human beings are subject and ways they are exhibited.

Some symptoms are early warning signs of potentially dangerous disorders that can be successfully treated.

Some diseases are often but not always progressive. Some diseases are temporarily incapacitating.

Still other diseases are permanently incapacitating.

Since the Working Group made its recommendations public, there has been a surge of interest in this problem, with discussions in the media. There has not, however, been an ofﬁcial response from any branch of government—judicial, legislative, or executive—possibly because one branch of government is loathe to interfere with the privileges and responsibilities of another. In my opinion, the easiest solution would be for the executive branch simply to implement the recommendations. Future chief executives probably would continue them (and be under considerable pressure to do so). Alternatively, legislation by Congress could serve the purpose. For the good of our nation, however, this matter must be considered at the highest levels of government and speedily resolved.